Have you ever found yourself wondering, ‘What happened with that patient that I took to hospital?’, ‘How are they doing?’ or ‘Did I do the right thing?’.
I often chase down the busy triage nurses in accident and emergency (A&E) to find out how my patients from earlier that shift are doing. Were they discharged? Was it a myocardial infarction? Did the bag of fluids I gave help their blood pressure? I'm always keen to find out if I did the right thing or – in all honesty – whether I have done anything wrong, so that I don't make a similar mistake again. It can be personally frustrating if for some reason I can't ‘scratch that itch’ so to speak – especially for the more complex patients or the rarer presentations. It is this desire to learn more that led me to start my journey towards a master's degree, which has introduced me to concepts that underpin the clinical decision-making we use as professionals.
Combined with a renewed appreciation for reflective practice and a view of the paramedic profession as a whole, I found myself lost in thought: could I confidently reflect on a particular incident if I didn't find out from A&E whether what I had done for my patient was correct? Could I meet the Health and Care Professions Council (HCPC) (2023) standards of proficiency on reflective practice adequately?
For a time, my local A&E had a dedicated QR-based feedback system for ambulance clinicians, which was organised by an emergency registrar who was also a paramedic. It allowed us to share an incident number and receive direct email feedback. However, this system is no longer in place as the registrar who provided the QR code and organised the system moved hospitals. Without this system, following up on patients can be very challenging. Last year, between March and September, an average of 50% of patients were taken to a hospital emergency department (NHS England, 2024). This statistic – which makes up a significant proportion of ambulance paramedics' patients – may never be followed up for reflective purposes. This could mean that a great many opportunities to learn and improve one's practice are being missed out on.
A small-scale qualitative study by Wilson et al (2022) found that frontline staff in one UK ambulance service had a ‘strong desire’ to receive feedback on the care they had delivered. Although the study did not look specifically at feedback on patients taken to the emergency department, it may not be too big of a stretch to assume that such feedback would be equally sought after, especially as we currently take nearly half of our patients there.
During a secondment in my trust's clinical hub doing telephone triage, I would receive random audits of multiple calls on a regular basis, provided by senior clinicians and marked against a standardised metric. On many occasions, I received constructive feedback that highlighted mistakes I had made. I would likely have continued making these mistakes otherwise, and my practice (and consequently the standard of care my patients received) would have suffered. These audits gave me clear focuses for reflections. As newly qualified paramedics (NQPs), we often receive ‘contact shifts’ with senior clinicians, whereby a mini-debrief is held after each incident, to discuss what went well and whether there is any room for improvement. Once we venture off as a band six, these become less frequent, so once we leave our patients at A&E, that is often the last we hear of it. Whether or not it was the right decision may never truly be known to us.
These ideas led me to wonder whether paramedics are vulnerable to a number of fallacies. The first of these is the ‘appeal to tradition’ fallacy. This explains how people tend to believe that an action that has always been done a certain way must be correct (Fallacy in Logic, 2020). It might lead a clinician to think, for example, ‘I've always taken falls patients to hospital, so why would I change my practice?’. Adding fuel to this fire is the ‘absence of evidence fallacy’, which occurs when you argue that your conclusion must be true, because there is no evidence against it (Texas State University, 2024).
If we believe in these fallacies as paramedics, it means that if we habitually transport a particular clinical presentation to A&E without receiving feedback on whether our practice was appropriate, we may inadvertently assume that what we are doing is therefore without fault. We may interpret no negative feedback as being a positive outcome. This in and of itself is not evidence that we can use to justify our practice.
If upon revisiting A&E, it was fed back to you that your transport of a patient had not been indicated, and that it had also resulted in that patient having developed hospital-acquired pneumonia, would this give you pause for thought? If you came across a similar clinical presentation in the future, would this event cause you to assess whether an appropriate alternative to A&E existed? However, if you are unaware that any problem exists, you will not be able to address it. By the same measure, you may never come to appreciate your successes if they are never highlighted to you.
Reflecting on the fact that we may not find out the clinical outcomes for our patients that we have transported to ED, may lead us to become more conscious in our thought process regarding why we felt that the emergency department was appropriate for our patient in the first place. When we decide to transport a patient to A&E, is our decision based on sound clinical reasoning or on ill-founded professional habit? Recognising this could also prevent clinicians from succumbing to the ambiguity effect and taking the ‘risk-averse’ approach of transporting a patient to the emergency department ‘just in case’, as this is ultimately unlikely to be in the patient's best interests. Personally, I would love to see it made easier for paramedics to receive feedback from A&E departments. A QR code system like the one previously operating out of my local emergency department could be a good solution.